Successful treatment of sino-pulmonary infection & skull base osteomyelitis caused by New Delhi metallo-ß-lactamase-producing Pseudomonas aeruginosa in a renal transplant recipient by using an investigational antibiotic cefepime/zidebactam (WCK 5222).

A case of sino-pulmonary infection with skull base osteomyelitis due to XDR-Pseudomonas aeruginosa in renal transplant recipient was successfully treated with investigational antibiotic, cefepime/zidebactam (WCK 5222). This case highlights challenges in managing XDR-pseudomonal infection where source control was infeasible, antibiotic options were extremely limited and individualized dose adjustments were needed.

A fatal misidentification: Burkholderia pseudomallei misidentified as Acinetobacter spp.

A middle-aged uncontrolled diabetic with chronic kidney disease presented with high-grade fever, skin abscesses and cough for two weeks. His blood cultures grew Burkholderia pseudomallei. A few weeks prior, blood cultures drawn for PUO workup elsewhere grew an organism identified as Acinetobacter sp with an unusual susceptibility pattern. His fever responded to a short course of meropenem. In retrospect, the earlier blood culture had likely misidentified B.pseudomallei as Acinetobacter sp given the background history, risk factors and the peculiar susceptibility report. Through this case, we discuss important aspects of melioid diagnostics which may be clinically relevant to establish this diagnosis.

A Unified Citywide Dashboard for Allocation and Scheduling Dialysis for COVID-19 Patients on Maintenance Hemodialysis.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has caused significant global disruption, especially for chronic care like hemodialysis treatments. Approximately 10,000 end-stage kidney disease (ESKD) patients are receiving maintenance hemodialysis (MHD) at 174 dialysis centers in Greater Mumbai. Because of the fear of transmission of infection and inability to isolate patients in dialysis centers, chronic hemodialysis care was disrupted for COVID-19-infected patients. Hence, we embarked on a citywide initiative to ensure uninterrupted dialysis for these patients. Materials and Methods: The Municipal Corporation of Greater Mumbai (MCGM) designated 23 hemodialysis facilities as COVID-positive centers, two as COVID-suspect centers, and the rest continued as COVID-negative centers to avoid transmission of infection and continuation of chronic hemodialysis treatment. Nephrologists and engineers of the city developed a web-based-portal so that information about the availability of dialysis slots for COVID-infected patients was easily available in real time to all those providing care to chronic hemodialysis patients. Results: The portal became operational on May 20, 2020, and as of December 31, 2020, has enrolled 1,418 COVID-positive ESKD patients. This initiative has helped 97% of enrolled COVID-infected ESKD patients to secure a dialysis slot within 48 hours. The portal also tracked outcomes and as of December 31, 2020, 370 (27%) patients died, 960 patients recovered, and 88 patients still had an active infection. Conclusions: The portal aided the timely and smooth transfer of COVID-19-positive ESKD patients to designated facilities, thus averting mortality arising from delayed or denied dialysis. Additionally, the portal also documented the natural history of the COVID-19 pandemic in the city and provided information on the overall incidence and outcomes. This aided the city administration in the projected resource needs to handle the pandemic.

The Effect of Higher and Lower Protein Intakes on Nitrogen Balance in Renal Transplant Recipients with Underlying Graft Dysfunction.

It is essential to determine the optimum protein intake in renal transplant recipients on steroids with renal dysfunction to maintain a neutral nitrogen balance. Our aim was to study the effect of higher (1.2 g/kg/day) and lower (0.8 g/kg/day) protein intakes on nitrogen balance, body composition, glomerular filtration rate (GFR), and proteinuria in renal transplant recipients with low estimated GFR (eGFR) (15-44 mL/min/1.73 m2). This prospective, open-labeled, randomized, cross-over, interventional study enrolled patients who were ≥4 months posttransplant with eGFR between 15 and 44 mL/min/1.73 m2. Subjects were randomized to either Group 1 [Diet: proteins (1.2 g/kg/day), 35 kcal/kg/day] or Group 2 [Diet: proteins (0.8 g/kg/day) and 35 kcal/kg/day] for one month. Subjects crossed over to the other diet for 2nd month. Body composition analysis, serum creatinine, blood urea nitrogen, serum protein, serum albumin, 24-h proteinuria, GFR measurement (24 h creatinine clearance), three-day diet recall and nitrogen balance estimation were performed at baseline and at the end of the first and 2nd month. Statistical analysis was performed using IBM SPSS Statistics version 21. Thirty-two of 35 patients completed the study. Three-day diet recall showed that daily protein and energy consumption was 1.2 g/kg and 36.47 kcal/kg with higher and 0.94 g/kg and 31.94 kcal/kg with lower protein diets, respectively. Nitrogen balance was +3.61 g/day (P = 0.0002) with higher and +1.66 g/day with lower protein diets. A significant increase was noted in muscle mass (P = 0.0317), blood urea nitrogen (P = 0.0118), GFR (P = 0.0114), and proteinuria (P = 0.010) with a higher protein diet. Renal transplant recipients remained in positive nitrogen balance with both diets. Muscle mass and proteinuria increased significantly with a higher protein diet.

Diarrhea in kidney transplant recipients: Etiology and outcome.

BACKGROUND AND AIM: Diarrhea in kidney transplant recipients influences outcome of transplantation. Data from India in this regard are sparse and do not address the differential outcome of infective and non-infective diarrhea. We studied the demographic data, laboratory findings, treatment response, disease duration, and outcome of diarrhea in kidney transplant recipients, and the differential outcome between infective and non-infective diarrhea, if any. METHODS: All kidney transplant recipients who were referred to the Division of Gastroenterology with diarrhea between June 2015 and February 2017 were prospectively included. Demographic, clinical and laboratory data, graft function, treatment administered, and outcome were noted, and the patients were followed up for 3 months. RESULTS: Forty-seven patients (median age 45 years, range 16-78; 34 men) with 64 episodes of diarrhea were studied. Thirty-three (51.5%) episodes were attributed to infections. Eleven (17%) were immunosuppressant-induced (mycophenolate 8, tacrolimus 2, cyclosporine 1). Twenty (31%) were due to other causes (antibiotics 6, laxatives 3, irritable bowel syndrome 3, sepsis 8). Fifty-three episodes (82%) had graft dysfunction during the diarrheal episodes. Mean increase in serum creatinine was 45% in the infectious diarrhea group and 95% in the non-infectious diarrhea group (p < 0.05). Median time to resolution of diarrhea was 3 days. With improvement in diarrhea, return to pre-diarrhea creatinine levels occurred in 87% of episodes at 3 months. CONCLUSION: One-half of episodes of diarrhea in kidney transplant recipients were non-infectious in origin. Seventeen percent were attributed to immunosuppressants, requiring dose modification. More than 80% were associated with worsening of graft function. Recovery of graft function to baseline was seen in a majority of cases with the resolution of diarrhea.

Is it Time to Rethink the Use of Steroids for Pulmonary Leptospirosis?

Pulmonary involvement is a fairly common complication of leptospirosis. A high dose of steroids is often used in the treatment of pulmonary leptospirosis. Here we report two cases who developed severe invasive fungal infections following the use of steroids for pulmonary leptospirosis. Routine use of steroids for pulmonary leptospirosis may do more harm than good as the evidence for this practice is sparse.

Colo-vesical fistula presenting as urinary tract infection.

We report a 59 years male who presented with urinary tract infection due to a colovesical fistula secondary to colonic diverticuli.

A young female with quadriparesis.

We report a case of a young female who presented with acute onset quadriparesis secondary to severe hypokalemia. She was normotensive and had no metabolic alkalosis or kaliuresis. Serum potassium was corrected over the next few days and the quadriparesis resolved completely. A detailed history later on revealed that she had been consuming alternative medication for infertility for a prolonged duration and had discontinued it a month prior. One of the ingredients of this medicine was Glycyrrhiza glabra.

Acute renal tubular injury with acute hepatitis A infection: is it just a coincidence?

Acute renal failure has rarely been reported in association with acute hepatitis A infection. The commonest form of renal injury in such patients has been found to be acute tubular necrosis. We report two cases of hepatitis A infection in which acute renal failure occurred very early in the course of the illness and had a clinical presentation and recovery pattern suggestive of acute tubular necrosis. In both patients, the clinical course of renal dysfunction was almost parallel to the course of hepatic dysfunction. Patient 1 needed dialysis, whereas patient 2 did not need dialysis and had a very rapid recovery from renal function in spite of having more severe azotaemia. Patient 2 was administered acetylcysteine in high doses for suspected fulminant hepatic failure. A potential benefit of a high dose of acetylcysteine in recovery of renal function from acute tubular necrosis is postulated.

Comparing serology, antigenemia assay and polymerase chain reaction for the diagnosis of cytomegalovirus infection in renal transplant patients.

BACKGROUND: Cytomegalovirus (CMV) disease is responsible for significant morbidity and mortality following renal transplantation. Currently serology is the only method widely available in our country. Newer methods like early CMV pp65 antigenemia assay and CMV DNA amplification can diagnose CMV disease in its very early period. AIM: The aim of our study was to compare serologic method with antigenemia assay and CMV DNA amplification to diagnose CMV. METHODS: Seventy-three renal transplant recipients (from 7 centres) with clinical suspicion of CMV disease were studied prospectively. The diagnosis of CMV infection was suspected on the basis of fever and leucopenia. RESULT AND DISCUSSION: Three tests were done in all 73 patients and in 22 healthy subjects (control group). The sensitivity and specificity of serological test (CMV IgM) was 72.97 and 62.06%; of antigenemia assay was 89.18 and 100% and of PCR was 100 and 72.41%. CONCLUSION: Antigenemia assay is a sensitive and specific test for early and rapid diagnosis of CMV infection. Qualitative PCR is a sensitive marker but has low specificity.